Newborn Sepsis Clinical Practice Guideline

Identifying newborns at risk for sepsis remains challenging. Please continue to use clinical judgment when evaluating individual babies.
Bacterial sepsis continues to be a major cause of morbidity and mortality in newborns. The CDC defines early onset sepsis as a blood or cerebrospinal fluid culture-proven infection occurring with the first 7 days of life. The incidence has been reduced by intrapartum antibiotic prophylaxis for the prevention of early onset group B Streptococcal (GBS) disease from approximately 2/1000 infants in the early 1990s to 0.3/1000. GBS is still the most common pathogen; more than half of GBS cases occur in infants of mothers with negative GBS cultures, emphasizing the need to remain vigilant for signs of sepsis in all newborns. Other etiologies include E. coli, other Streptococcus species, Enteroccocus, and Staph aureus. RISK FACTORS FOR SEPSIS INCLUDE (see management below): Chorioamnionitis Infant of multiple births where one newborn has GBS sepsis Prolonged rupture of membranes > 18 hours Maternal intrapartum temperature > 38.0 C GBS positive mother with inadequate treatment (less than 4 hrs) Previous infant with early onset GBS sepsis Additional signs of sepsis may include the following: fetal tachycardia fever hyperbilirubinemia apnea hypoglycemia hypotonia lethargy hypothermia pallor tachypnea grunting bulging fontanelle temperature instability tachycardia abd distention

INFANTS REQUIRING IMMEDIATE COMPLETE DIAGNOSTIC EVALUATION AND INITIATION OF EMPIRIC ANTIBIOTIC THERAPY: 1. Infants with signs or symptoms of sepsis regardless of presence or absence of risk factors 2. Well appearing infants with the following risk factors: Chorioamnionitis Infant of multiple births, where one newborn is/has been diagnosed with GBS sepsis Complete diagnostic work up for sepsis includes: Complete blood count with differential, CRP, blood culture, serum glucose; repeat CBC, CRPs as appropriate Consider CXR if respiratory symptoms are present and lumbar puncture if clinically indicated. Consultation: NICU should be consulted to help guide further management decisions if an infant is undergoing an evaluation for presumed sepsis due to clinical signs/symptoms or if infant has a positive blood culture RISK FACTOR BASED SCREENING (see algorithm next page for specific management): Infants that require close observation for 48 hours, blood culture and serial labs regardless of GBS status include: Maternal intrapartum temperature > 38.0 C Prolonged rupture of membranes > 18 hours Gestational age < 37 weeks. Infants that require close observation for 48 hours, and serial labs include: Mothers with inadequate intrapartum antibiotic prophylaxis for GBS (none or less than 4 hours prior to delivery) ABNORMAL LABS THAT MAY WARRANT INITIATING TREATMENT OR CONSULTATION INCLUDE*: 1. WBC < 6,000 2. I/T ratio of > 0.3 3. Elevated CRP > 1.0 mg/dL

* regarding laboratory studies, the likelihood of sepsis increases substantially if multiple lab parameters are abnormal THERAPY:
Antibiotics (if meningitic dosages are necessary, consult Neofax) Ampicillin 50 mg/kg/dose STAT and then q 12 hours given IV, or IM initially if access difficult to obtain Gentamicin 4 mg/kg/dose STAT and then q 24 hours given IV, or IM initially if access difficult to obtain (levels pre-and post-third dose) Laboratory: If Blood culture positive- Consult Neonatology (will likely need repeat blood culture and CSF culture) Repeat CBC and CRP daily, until normalized

Clinical Guideline to Evaluate Newborns at Risk for Sepsis

Full Evaluation and Initiation of Therapy

Signs or symptoms of sepsis

Yes

No

CBC w/ differential, CRP, blood culture, serum glucose Therapy: Ampicillin and Gentamicin (see page 1) Follow up serial lab screening as indicated Length of treatment will depend on clinical course, culture results and lab studies. Consider CXR, lumbar puncture, electrolytes, ionized Ca pending clinical course

Maternal Chorioamnionitis

Yes

No

Any of the following? Rupture of membranes >18 hrs Maternal temp > 38.0 C < 37 weeks gestation
No

Limited Evaluation
Yes

Observation for > 48 hours; vitals q 4 hours during stay Blood culture, CBC and CRP at birth; CBC, CRP at 12hrs Additional CBC and CRP screening may be considered

GBS prophylaxis indicated for mother?**

Yes

No

ROUTINE NEWBORN CARE

Observation for > 48 hours; vitals q 4 hours during stay CBC and CRP at birth and 12 hours Observation for > 48 hours; discharge may occur after 24 hours if adequate home observation and access to medical care is assured.

No

Mother received intravenous penicillin, ampicillin or cefazolin > 4 hours before delivery
Yes

**GBS intrapartum prophylaxis indicated for:

GBS + screening culture in late gestation during current pregnancy except when delivery occurs by Csection with intact membranes before onset of labor GBS bacteruria during current pregnancy Previous infant with invasive GBS disease Unknown GBS status and any of the following- < 37 weeks gestation, ROM >18 hrs, or maternal fever (> 38.0 C)

Algorithms are not intended to replace providers clinical judgment or to establish a single protocol. Some clinical situations may not be adequately addressed in this guideline. Clinicians should document management variations or plans of care as indicated. Last
revised November, 2011 by the Newborn Nursery GBS sub-committee. Ref: MMWR Prevention of Perinatal Group B Steptococcal Disease, Revised Guidelines from CDC, 2010. Nov. 19, 2010/Vol.59/No.RR-10